Despite dramatic improvements, malaria remains a significant health problem in many regions of the world. As malaria programs move from control to elimination, there is an urgent need to understand barriers to and facilitators of the use of control measures. In this proposal, we focus on the most widely used control measure; bednets in a highland/low transmission and a lowland/high transmission. Our preliminary results indicate that in Kenya roughly 1 in 4 children under 5, the group most vulnerable to malaria, live in households that do not own a bednet. Additionally, even in net owning homes, 1 in 6 children under 5, do not sleep under a net. As Kenya and other programs expand their scope to distribute enough nets to cover all household members, much effort needs to go into understanding the prevalence of and factors related to disuse. The objective of the following proposal is to use qualitative and quantitative methods to determine the prevalence of ownership, misuse and disuse of bednets under field conditions and to identify modifiable risk factors. We will use an ecological approach to assess not only individual level factors that drive bednet ownership and use but the social and environmental context in which these decisions are being made. Following focus group discussions with community members and key informant interviews with health clinic staff, government vector control staff and village and community leaders, we will conduct a cross-sectional survey that examines 1) perceived susceptibility to malaria 2) perceived severity of malaria 3) perceived benefits of ITN use 4) perceived barriers to ITN use 5) cues to action such as health promotion programs and 6) confidence in the subject's self-efficacy with regard to obtaining an ITN and its proper use. We will use remotely-sensed images and GIS to determine how these perceptions and practices vary geographically and if they correspond with actual risk as determined through parallel parasite prevalence surveys and pyrethrum spray catches of Anopheles. From the cross-sectional participants we will identify positive deviants, community members who own and use bednets regularly despite experiencing at least 75% of the factors associated with not owning or using a bednet. In-depth interviews will be conducted to determine their solutions and personal motivators that may be used to improve community bednet ownership and compliance. Our approach is unique in its combination of rich qualitative data and the rigor and generalizability of established epidemiologic methods. Identifying what is already working in a community is more likely to be successfully implemented as a larger intervention. We expect that we will find that individuals who have personal loss due to malaria, have identified solutions to logistical issues with hanging bednets, have a higher perception of risk and who have greater access to household resources will be more likely to own and use a bednet. This research will help drive the development of targeted community-based interventions that should improve ITN ownership and use and ultimately reduce malaria transmission. PUBLIC HEALTH RELEVANCE: Malaria causes an estimated 800,000 deaths each year. Insecticide treated nets (ITN) are the most effective strategy to prevent malaria. This study will advance understanding of barriers and facilitators to ownership and use of ITN in malarious areas. We will use a mixed methods approach to identify simple solutions that will improve ownership and compliance with ITN use in western Kenya.